Search

The authors examine differential progress on health Millennium Development Goals (MDGs) between the poor and the better off within countries. Their findings are based on an original analysis of 235 Demographic and Health Survey (DHS) and Multiple Indicator Cluster Survey (MICS) surveys spanning 64 developing countries over the 1990–2011 period. The authors track five health status indicators and seven intervention indicators from all four health MDGs. In approximately three-quarters of countries, the poorest 40 percent have made faster progress than the richest 60 percent on MDG intervention indicators. On average, relative inequality in these indicators has been falling. However, in terms of MDG outcome indicators, in nearly half of the countries, relative inequality has been growing. Moreover, in approximately one-quarter of the countries, the poorest 40 percent have been slipping backwards in absolute terms on both MDG interventions and outcomes. Despite reductions in most countries, relative inequalities in MDG health indicators are still appreciable, with the poor facing higher risks of malnutrition and death in childhood and lower odds of receiving key health interventions.

Ethiopia’s remarkable socio-economic transformation over the last decade has been marked by: a reorientation of expenditure from recurrent to capital; a significant devolution of resources from Federal Government to Regions; and a clear prioritization of infrastructure spending, while protecting spending on education at four percent of GDP. The Government of Ethiopia has also leveraged external resources to boost spending in pro-poor sectors, particularly health and social protection. As a result, Ethiopia is home to the largest social safety net program in Africa, and has also achieved remarkable health outcomes using cost effective approaches. Recent investments have seen a significant build-up of capital stock, with capital spending at sector level pointing towards increased service capacity. The current public investment-led strategy requires to be complemented by increased budgetary provisions in operations and maintenance so that new investments translate into enhanced service coverage and delivery. As Ethiopia lays the foundation to become a middle income country, and the changing global environment implies declining external assistance, it is imperative that domestic taxation activity support this transition. The current tax-to-GDP ratio is low compared to peer countries, and the tax structure would benefit from increased contributions by direct tax sources. Therefore, there is an immediate need for advancing tax reforms and improve capacity and quality of tax administration. Broadening the tax bases, through review of exemptions, as well as review of tax rates might be venues to consider. Additional revenues will create the much-needed fiscal space to increase funding for operations and maintenance for service delivery, and support fiscal sustainability. As a follow-up to this Public Expenditure Review, the Government of Ethiopia has asked the World Bank to provide further analytical support, with a view to enhance domestic revenue mobilization through simpler and more efficient taxation, while retaining equity priorities in public finances.

It is increasingly recognized that India is urbanizing rapidly, that urbanization is accompanying and contributing to economic growth, but that living conditions in urban areas are often not adequate, particularly for the poor. Health, nutrition, and population conditions are an important part of the urbanization equation. This paper explores the extent to which health, nutrition, and population conditions may be contributing to the benefits of urbanization, as well as the extent to which they may reflect its costs. This is an exploratory study that reviews available information on health, nutrition, and population conditions in urban India. Recognizing that national generalizations and statistics may mask considerable diversity in how the opportunities and challenges of urbanization and health are met in different cities across the country, this paper also draws on specifics of four case studies: Chennai in Tamil Nadu, Bhubaneswar in Odisha, Meerut in Uttar Pradesh, and Shillong in Meghalaya. The summary section provides an overview of this exploratory analysis, discussing the patterns and issues that emerge, along with policy implications in section one. This introductory section two briefly discusses how urbanization and health may be conceptualized, and describes the methodology of this paper. Section three describes governance and organization of urban health systems. Sections four and five review data on the demographic and epidemiological situation in urban India, as well as service utilization. Section six analyzes disparities in health outcomes and access to services, and section seven focuses on water supply and sanitation in urban areas.

Improved outcomes for women and children - more education, lower fertility rates, higher nutritional status, and lower incidence of illness, among other outcomes - have broad individual, family, and societal benefits. For nearly 15 years, the targets of the millennium development goals (MDGs) have been a bellwether for progress, particularly for maternal and child health (MCH) - a two-thirds reduction in under-five mortality in MDG 4 and a three-quarters reduction in the maternal mortality ratio in MDG 5. This systematic review by the Independent Evaluation Group (IEG) is a learning exercise that looks beyond World Bank experience. It is intended to be used a reference for practitioners in the Bank and elsewhere with an interest in interventions that have demonstrated attributable improvements in skilled birth attendance and reductions in maternal and child mortality. This review also identifies important gaps in the impact evaluation evidence for interventions that may be effective in reducing maternal and child mortality but whose impacts have not yet been tested using robust impact evaluation methods. The systematic review provides findings on what is known about the effects of interventions on skilled birth attendance, maternal mortality, neonatal mortality, infant mortality, and under-five mortality, as well as the effect of skilled birth attendance on these and other intermediate MCH outcomes. Finally, the review highlights the main gaps in the body of impact evaluation knowledge for maternal and child mortality.

This report analyses equity and financial protection in the health sector of Timor-Leste. In particular, it examines inequalities in health outcomes, health behavior and health care utilization; benefit incidence analysis; financial protection; and the progressivity of health care financing. Data are drawn from the 2009-2010 Demographic and Health Survey, the 2001-2002 and 2007-2008 Living Standards and Measurement Surveys as well as 2011-2012 Household Income Expenditure Survey, and the Ministry of Finance. All analyses are conducted using original data and performed using the health modules of the ADePT software.

This study examines the determinants of adolescent sexual behavior and fertility in Nigeria, with a special focus on knowledge, attitudes and behaviors of adolescents aged 10-19 years old in Karu Local Government Authority (LGA), a peri-urban area near the capital city of Abuja. Using the last three waves of Demographic and Health Surveys (2003, 2008, 2013), focus group discussions, stakeholder interviews, and a specialized survey of 643 girls and boys aged 10-19 years old in Karu LGA, the study narrows in on key challenges to and opportunities for improving adolescent sexual and reproductive health outcomes. The national median age at sexual debut for adolescent girls and boys is between 15 and 16 years of age. This is closely emulated in Karu LGA with a median age of 14.8 years for girls and 15.3 years for boys. While data on pregnancies was limited in the Karu sample, DHS data show that for girls, sexual debut is closely associated with marriage or cohabitation, which in turn is a strong predictor of adolescent fertility. Poverty is another strong predictor, with the odds of becoming pregnant being twice as high for adolescents in the lower wealth quintiles compared to their counterparts in the richest quintile in the country. While adolescents’ knowledge of contraception has increased from under 10 percent to over 30 percent, use of health services among adolescents for SRH (and contraception) is limited due to factors such as fear of stigma, embarrassment, and poor access to services, something also emphasized in focus group discussions. Challenges for improving adolescent SRH outcomes relate to: (i) the paucity of data, especially on the 10-14 year olds; (ii) availability and access to youth-friendly services and the Family Life and HIV Education (FLHE); (iii) reaching out-of-school adolescents with SRH information; and (iv) addressing ambiguities and gaps in Federal law and customs on age at marriage, and generating support for the legal age at marriage of at least 18 years old. Addressing these barriers at the State and sub-regional levels is going to be critical in improving adolescent well-being.

Recent surveys show considerable progress in maternal and child health in Ethiopia. The improvement has been in health outcomes and health services coverage. The study examines how different groups have fared in this progress. It tracked 11 health outcome indicators and health interventions related to millennium development goals one, four, and five. These are stunting, underweight, wasting, neonatal mortality, infant mortality, under -five mortality, measles vaccination, and full immunization, modern contraceptive use by currently married women, antenatal care visits, and skilled birth attendance. Trends in rate differences and rate ratios are analyzed. The study also investigates the dynamics of inequalities, using concentration curves for different years. In addition, a decomposition analysis is conducted to identify the role of proximate determinants. The study finds substantial improvements in health outcomes and health services. Although there still exists a considerable gap between the rich and the poor, the study finds some reductions in inequalities of health services. However, some of the improvements in selected health outcomes appear to be pro-rich.

The last few years have seen a growing commitment worldwide to universal health coverage (UHC). Yet there is a lack of clarity on how to measure progress towards UHC. This paper proposes a ‘mashup’ index that captures both aspects of UHC: that everyone—irrespective of their ability-to-pay—gets the health services they need; and that nobody suffers undue financial hardship as a result of receiving care. Service coverage is broken down into prevention and treatment, and financial protection into impoverishment and catastrophic spending; nationally representative household survey data are used to adjust population averages to capture inequalities between the poor and better off; nonlinear tradeoffs are allowed between and within the two dimensions of the UHC index; and all indicators are expressed such that scores run from 0 to 100, and higher scores are better. In a sample of 24 countries for which there are detailed information on UHC-inspired reforms, a cluster of high-performing countries emerges with UHC scores of between 79 and 84 (Brazil, Colombia, Costa Rica, Mexico and South Africa) and a cluster of low-performing countries emerges with UHC scores in the range 35–57 (Ethiopia, Guatemala, India, Indonesia and Vietnam). Countries have mostly improved their UHC scores between the earliest and latest years for which there are data—by about 5 points on average; however, the improvement has come from increases in receipt of key health interventions, not from reductions in the incidence of out-of-pocket payments on welfare.

Worldwide, deaths from cancer exceed those caused by human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS), tuberculosis, and malaria combined. Seventy percent of deaths due to cancer occur in low-and middle-income countries, which are often poorly prepared to deal with the growing burden of chronic disease. Over a period of 18 months, the cancer care and control South-South knowledge exchange brought together a group of stakeholders from five countries in Africa - Botswana, Kenya, Rwanda, Uganda, and Zambia to share experiences, lessons, and good practices through a set of video conferences and a site visit to Zambia. All five countries have demonstrated commitment, initiated various cancer control and cancer screening programs, and expressed interest in sharing their experiences. The knowledge exchange on cancer care and control aimed to raise awareness, increase knowledge of effective strategies, and strengthen regional collaboration in cancer control planning and expanding equitable access to cancer treatment. This paper presents highlights of the country experiences shared, common challenges discussed, and innovative solutions explored during the knowledge exchange. Topics addressed include population-based surveillance and data collection to better document the burden of cancer; strategies for designing and implementing successful national cancer care and control programs; innovative approaches for strengthening cancer prevention efforts such as human papilloma virus (HPV) vaccination programs; task sharing and other strategies to build capacity and increase access to services; analytical tools for understanding the costs of programs; financing models, including public private partnerships, to increase cancer prevention and care; policy reforms needed to improve access to palliative care; and opportunities for regional collaboration.

The background study for the national strategy on social inclusion and poverty reduction 2015-2020 was produced under a RAS agreement with the Ministry of Labor, Family, Social Protection, and Elderly of Romania. The report is a companion volume of the strategy, adopted by the Romanian Government in May 2015, and summarizes the diagnostics and analyses carried out by the World Bank team to provide a sound empirical base for the strategy. Given the multi-dimensional nature of poverty, the report includes diagnostics and policy recommendations on employment, social protection, education, health, housing, social participation, as well as regional and rural development policies. The document is based on a combination of desk research, qualitative data analysis, new data collected by the World Bank team and analyses of administrative, census, and survey data. This included qualitative research (for example, case-studies in two counties, interviews with representatives of central governmental bodies, interviews with recipients and eligible potential beneficiaries of means-tested benefits and with social workers), and quantitative data collection and analysis (a census on social housing stock; census of frontline social workers; a consolidated database of physicians, representatives of the pharmacies, community nurses, and health mediators; administrative dataset with social services for elderly, social services for people with disabilities and specialized child protection services; analysis of poverty. The book is organized in four parts. The first part starts with an analysis of the trends in poverty and social exclusion over the past few years and with a poverty forecast for the next five years (2015 to 2020). The second part analyzes the sectoral policies that must be implemented to tackle the problems identified in the first part of the volume. The third part turns its focus to area-based policies and discusses regional disparities, urban-rural differences, and specific problems in small towns and villages, rural, and urban marginalized areas, and Roma and non-Roma communities. The fourth part discusses the actions needed to strengthen the capacity of the public system to reduce poverty and increase social inclusion.

This document details the scope and the main elements of the Country Partnership Framework (CPF) with the Republic of Botswana for FY16-20. The previous Country Partnership Strategy (CPS), considered by the Board on May 21, 2009 and completed in 2013 has built a solid foundation to design the new World Bank Group (WBG) program. The CPF supports the government’s ongoing National Development Plan (NDP10) that has recently been extended until 2017. It also reviews the new NDP11 now under preparation. The Systematic Country Diagnostic (SCD) was completed after Botswana’s General Elections in October 2014. The SCD drew on all available research and benefited greatly from the series of stakeholder consultations conducted in the country between March and September, 2014. The report was well received by the national authorities and sent for information to the Board on March 31, 2015. The SCD identified the following priority development challenges: (a) despite rapidly declining poverty, low job creation keeps inequality extremely high; (b) with the weakening of traditional growth drivers, a new growth model is needed that is jobs-intensive, export-oriented, and private sector-driven; (c) despite broad and well-intentioned investment, inclusion barriers remain; (d) sustainability is threatened as resource vulnerability challenges long-term growth and inclusion.

Latin America and the Caribbean (LCR) will be center stage in the global development debate as leaders from around the world convene in Lima, Peru for the annual meetings of the World Bank Group and International Monetary Fund. Critical progress in poverty reduction has been made in the region over the last decade. The region’s bottom 40 percent of the population saw growth eclipsing that seen by the group in every other region in the world. However, a global slowdown in economic growth and activity challenges these positive strides. The stories in this report embody concrete successes of countries working together with the World Bank. Innovative development approaches were designed and implemented. Individuals, communities, countries, and even regions benefited from better health, education, governance, disaster risk management, and more.

The objective of this report is to assess public financial management (PFM) systems existing at the province level with a particular focus on the health and education sectors, and to understand linkages existing between the institutional settings in these two sectors and PFM processes. By doing so, the report shows the direct impact of poor PFM on service delivery in health and education. Since these two sectors have significant effects on the bottom 40 percent of the population, this will help Argentina’s subnational governments allocate and use public resources more efficiently, and with greater accountability for their expenditure.

Union Budget policies in Myanmar have undergone fundamental shifts since 2011 to accelerate delivery of essential public services. This first ever Public Expenditure Review (PER) for Myanmar tries to better understand these shifts and recommend ways to further align budget policies to development priorities. The Myanmar PER 2015 is divided into five parts: (i) sustainability of aggregate fiscal policy; (ii) rebalancing the composition of the Union Budget; (iii) improving coverage, quality and equity of education services; (iv) going from more to better government spending on health; and (v) a sound fiscal framework for sub-national service delivery. The book is arranged as follws: (i) chapter one starts with introduction; (ii) chapter two deals with sustainability of aggregate fiscal policy; (iii) chapter three focuses on rebalancing the composition of the union budget; (iv) chapter four deals with improving the coverage, quality and equity of education; (v) chapter five suggests from more to better government spending on health; and (vi) chapter six talks about fiscal framework for sub-national service delivery.

Verification differentiates results-based financing (RBF) from other health-financing mechanisms, and it is considered an important process of RBF program design and implementation. Despite the vital role it plays in RBF, not much has been written about verification as a process, and information about different elements of the process, frequency, cost, and direct and indirect effects among others, is scarce. Panama’s Health Protection for Vulnerable Populations Program (PSPV) uses an RBF mechanism to deliver health services to the country’s rural poor. As in many RBF schemes, a major component of the PSPV is the verification of results. This study focuses on PSPV’s verification process, highlights its results and their application, and identifies lessons learned. Such information is useful to policy makers and technical experts interested in or designing RBF mechanisms.

The ongoing Ebola outbreak in West Africa has put a huge strain on already weak health systems. Ebola deaths have been disproportionately concentrated among health care workers, exacerbating existing skill shortages in Guinea, Liberia, and Sierra Leone in a way that will negatively affect the health of the populations even after Ebola has been eliminated. This paper combines data on cumulative health care worker deaths from Ebola, the stock of health care workers and mortality rates pre-Ebola, and coefficients that summarize the relationship between health care workers in a given country and rates of maternal, infant, and under-five mortality. The paper estimates how the loss of health care workers to Ebola will likely affect non-Ebola mortality even after the disease is eliminated. It then estimates the size of the resource gap that needs to be filled to avoid these deaths, and to reach the minimum thresholds of health coverage described in the Millennium Development Goals. Maternal mortality could increase by 38 percent in Guinea, 74 percent in Sierra Leone, and 111 percent in Liberia due to the reduction in health personnel caused by the epidemic. This translates to an additional 4,022 women dying per year across the three most affected countries. To avoid these deaths, 240 doctors, nurses, and midwives would need to be immediately hired across the three countries. This is a small fraction of the 43,565 doctors, nurses, and midwives that would need to be hired to achieve the adequate health coverage implied by the Millennium Development Goals. Substantial investment in health systems is urgently required not only to improve future epidemic preparedness, but also to limit the secondary health effects of the current epidemic owing to the depletion of the health workforce.

Haiti has a vision to become an emerging economy by 2030. Haiti has comparative advantages, including its proximity and access to major markets; a young labor force and a dynamic diaspora; and substantial geographic, historical, and cultural assets. Areas of economic opportunity for Haiti include agribusiness, light manufacturing, and tourism. Recognizing these opportunities, the Government of Haiti issued in May 2012 a strategic development Plan (PSDH), aiming at building a new modern, diversified, resilient, competitive, and inclusive economy, respectful of its environment and in which people’s basic needs is met. This report examines more particularly how to: (i) mobilize greater fiscal revenue; (ii) enhance the growth dividend of public investment; (iii) improve the efficiency of spending in critical sectors such as health, education, and social protection; and (iv) protect the budget from a return of fuel price subsidies. This report builds on newly available data, including the 2012 household survey, the 2012 demographic and health survey (DHS), and the 2011-12 school census, to provide a better understanding of the equity and sustainability issues in the delivery of some basic services such as health and education, and engage policy makers and other actors on gaps and priorities.

This document presents the Systematic Country Diagnosis (SCD) for Mali. The SCD was prepared following a consultative process within and outside the World Bank. It identifies constraints and opportunities for achieving the twin goals of ending poverty and improving shared prosperity by 2030 while acknowledging (i) the need for selectivity in pro-poor interventions, and (ii) the many competing ‘binding’ reasons for poverty in Mali. The objectives of the twin goals are similar for Mali as the incidence of dollar-a-day poverty exceeds 40 percent of the population. Selectivity means the identification of principal opportunities for poverty reduction in the next 15 years, as well as the identification of binding constraints to reaping such opportunities. In the search for selectivity, there is the risk of not identifying the correct set of opportunities and constraints. However, the risk of not being selective would probably have more serious implications as it could lead the government and its development partners to disperse their resources and attention too thinly over too many competing priorities. Selectivity also implies making trade-offs between immediate and longer term objectives. In this document priority is given to the identification of poverty reduction opportunities which could deliver results before 2030, while acknowledging that efforts should not undermine the prospects for poverty reduction and shared prosperity beyond 2030. In this regard, particular attention is paid to environmental and fiscal sustainability.

The evolution of Costa Rica’s social sectors over the past decade has been dichotomous. On the one hand, economic growth has remained relatively high, however poverty and inequality have not declined (moreover, they have increased), and persistent employment challenges remain. On the other hand, the country has continued experiences advances in many social indicators, such as pre-primary and tertiary enrollment rates, access to improved sanitation, and labor force participation, though not in others (secondary school completion, immunizations, employment). Higher economic growth and (to a lesser extent) revenues seem to have allowed a substantial increase in public social spending. Looking forward, the key challenges Costa Rica faces are related to continuing improving the quality and efficiency in the social sectors, while improving targeting to serve the most in need, in a tight and severe fiscal context. To expand coverage of excluded population, priority will have to be given to reallocations and improvements within the spending envelope for the social sectors to maximize impact. With a fiscal deficit of more than 6 percent of GDP, further expanding public social spending is no longer an option and budget cuts are looming. Improvements in public spending management and budget execution, including the need of institutional reform to consolidate programs and improve coordination among executing agencies is equally important. In a country that has long been the champion in expanding universal welfare state, sustainability concerns will imply that hard fiscal decisions would need to be made to increase the social returns of budget allocation.

This Public Expenditure Review (PER) for health in Zimbabwe is an analytical report developed by the World Bank Health, Nutrition and Population Task Team working with the World Bank’s Macroeconomics and Fiscal Management Global Practice team, Zimbabwe’s Ministry of Finance and Economic Development (MOFED) and Ministry of Health and Child Care (MOHCC), with input from development partners. The aims of the PER are to provide objective evidence to inform the allocation of resources to enable equitable, efficient, and sustainable health care provision and to highlight questions about health sector performance for policy makers and key stakeholders. The findings also aim to present Zimbabwe’s health sector spending in an international and regional perspective, highlighting key issues for improving health outcomes. The PER is based on analysis of primary and secondary data as well as an extensive review of existing literature. The research was complemented by interviews with key stakeholders, and data collection from major development partners and domestic health funders, including private companies. Micro-level data from household and health facility surveys in May–August 2014 (primarily for the impact evaluation of the Results-Based Financing (RBF) program supported by the World Bank) complemented these scarce data.

The HIV epidemic amongst men who have sex with men (MSM) in Bangkok is substantial. The population size of MSM in Bangkok is 120,000-250,000, with approximately one-third (33.5 percent) considered high-risk, characterized by their young age, multiple partnerships, frequent unprotected anal intercourse, and sexual activities around MSM hotspots. In metropolitan Bangkok, HIV prevalence among MSM reportedly increased from 21 percent to 28 percent between 2000 and 2012. The Thai Working Group of Estimation and Projection (2013) projected an estimate of 39,000 new HIV infections would occur in Thailand during 2012-2016, based on the AIDS Epidemic Model (AEM). MSM will account for 44 percent of these new HIV cases, and 25-30 percent of these infections will likely to occur in Bangkok. In 2011, the United Nations held a high-level meeting on HIV/AIDS where they adopted the ambitious epidemiological targets of the United Nations Political Declaration on HIV/AIDS (UNPD), to be met by 2015. Attaining these specific targets would lead to substantial progress towards ending AIDS. UNAIDS has also been prioritizing the “Getting to Zero” initiative (“Zero new HIV infections. Zero AIDS-related deaths. Zero discrimination.”). The Bangkok Metropolitan Administration (BMA) recently responded with the “Bangkok: Getting to Zero” initiative, which strategizes an increased focus on prevention amongst MSM in the city. The clinical trial, HPTN052, demonstrated a 96 percent reduction of HIV transmission among heterosexual discordant couples who received ART. “Treatment as prevention” has become an increasingly accepted strategy to prevent new infections. A cost-effectiveness analysis comparing current levels of investment in targeted HIV prevention interventions for MSM in Bangkok (including treatment), with scenarios of increased coverage, would provide evidence to shape efficient national and metropolitan strategies. A return-on-investment analysis would provide an economic rationale to finance this strategy in allocating sufficient resources to address the epidemic at the most appropriate scale. Demonstration by the study that a significant reduction in transmission (including potential elimination) are both feasible and cost effective, may galvanize global political support.

Health financing in Bulgaria is organized in a way that should, in theory, allow the system to deliver good performance. In particular, the national health insurance fund was set up to provide universal coverage, and the provider-payment system contains elements of international best practices. The hospital-centric service delivery structure is not well targeted to the predominant and growing burden of non-communicable diseases, and loopholes in the provider-payment system reinforce this bias toward expensive hospital care. The first part of this report presents a health financing diagnostic to assist the Government of Bulgaria in developing health financing reform options that improve the efficiency, equity, and long-term sustainability of the Bulgarian health system. The second part reviews the reform agenda currently envisaged by the government with a focus on health financing aspects. It presents practical suggestions, drawn from international experience, which should support the government as it moves toward implementing its reform agenda. These suggestions aim to enhance the reforms’ capacity to address some of the performance gaps highlighted in part one with respect to efficiency, sustainability, and capacity to provide financial protection.

Bulgaria under the guidance of the Minister of Health is undertaking a major reform of its health system. One input to the reform is a joint study with the World Bank on health financing in Bulgaria (The World Bank Diagnostic Report). The report evaluates the strengths and weaknesses of Bulgaria’s health financing system in terms of the three health financing functions of revenue raising, risk pooling, and purchasing of services. It assesses each of these financing functions in terms of the health financing goals of improving health outcomes, financial protection, and consumer responsiveness in an efficient, equitable, and sustainable manner. The assessment of the health financing system documented significant strengths in the system, but also major challenges in terms of the purchasing function and current hospital payment practices. These challenges included unsustainable growth in hospital spending; lack of incentives for efficiency, quality, or cost control, and strong incentives for hospitalization over treatment in less expensive outpatient settings. Fundamental problems with the current hospital payment system using Clinical Care Pathways (CCPs) were highlighted. The purpose of this report is to provide information to Bulgarian decision-makers on how Bulgaria can move towards implementing a DRG-based hospital budgeting and payment system. The report was prepared by a team of Bulgarian and international DRG experts who have been involved in the country’s DRG assessment and planning since its inception. The report is intended for a wide-ranging audience that includes high-level policy-makers who are weighting the benefits of implementing DRGs, technical staff who may be tasked with implementing the Action Plan, and other key stakeholders who may be less familiar with the use of case-mix as a mechanism to provide payment to hospitals.

Nigeria is a country of immense natural resources and potential, but the government’s capacity to deliver public goods has generally been weak. It was against this backdrop that Nigeria faced the arrival within its borders of the deadly Ebola virus disease in July 2014. Despite assurances that the Nigerian government was prepared to respond to an outbreak of Ebola, the country was caught unaware and forced to mount an emergency response. Yet despite these serious concerns, the spread of Ebola was successfully contained in Nigeria. This case study seeks to understand why Nigeria’s Ebola response was so successful despite the challenging context. The case study will focus on institutional architecture and political will, taking an exploratory qualitative approach to examine the institutional dynamics and motivations among various stakeholders involved in the country’s response. The aim is to distill lessons that may be applied to other emergency response initiatives, as well as elsewhere in the health sector and in other areas of service delivery. A proactive communication strategy is required to build a broader coalition of support, and demand-side actors such as nongovernmental organizations play a helpful role.

Results-based financing (RBF), which rewards providers, users, or administrators of services upon achieving a set of verified results, has been gaining attraction in global health as a prominent approach to gain value for money. With a large number of countries adopting RBF in the recent years, evidence starts to emerge which points to the effectiveness of RBF in improving coverage and quality of important services, such as maternal and child health and reproductive health. The current toolkit aims to support country programs to assess the cost-effectiveness of RBF interventions and to facilitate cross-country comparisons of RBF programs. The toolkit is specifically tailored to supply-side RBF but its general principles apply to most health systems interventions directed at the health-related millennium development goals (MDGs). The development of the toolkit was based on actual experience of conducting a cost effectiveness analysis of Zambia’s RBF program and an extensive review of RBF programs features across the health results innovation trust fund (HRITF) portfolio. Given that RBF programs in the HRITF portfolio are typically complex health system interventions, the toolkit recommends a practical approach of adopting a program implementer’s perspective and presents different options for cost-effectiveness analysis (for selected key indicators or for an entire package of services). It also provides guidance on incorporating quality of care, which is strongly emphasized across many RBF programs.

In an effort to bridge the evidence gap, the Independent Evaluation Group (IEG) prepared a systematic review that gathers and analyzes the available impact evaluation evidence in developing countries from 1990 to 2013 on whether early childhood interventions shape future outcomes. Its purpose is not to supplant existing evidence but rather to help practitioners understand how evidence from impact evaluations supports or challenges beliefs about interventions and can be used to inform development policy. This review aims to answer two questions: (1) What is the evidence of attributable effects on outcomes in primary school and beyond from interventions in low- and middle-income countries that occur during the early childhood period? and (2) How do the post-early childhood effects of early childhood interventions vary by socioeconomic status, gender, age at intervention, and age at evaluation, particularly during the first 1,000 days from conception to the childs second birthday and from age three to primary school enrollment at age five to six? This report reviews all interventions from developing countries that occur during early childhood for which impact evaluation estimates exist for effects observed at primary school age and older. From an initial search of thousands of studies, the search process which included database searches, hand searches, and snowballing identified more than 500 relevant impact evaluations written from 1990 to 2015. This review covers six areas or domains of human development: physical development, cognitive development, language development, socio-emotional development, schooling outcomes, and employment and labor market outcomes. These domains are commonly included in evaluations of early interventions targeting poor children because they are negatively affected by early poverty, can benefit from early intervention, and are important for overall well-being or adult productivity. Some outcomes can be measured repeatedly starting from early childhood (i.e., height and weight) while others are only measurable later in life (i.e., cognition, schooling, and employment and labor market status).

The year 2015 is pivotal in international development. In the lead-up to 2000, the global community came together at various conferences to agree on, for the first time in known history, shared development goals. The eight Millennium Development Goals (MDGs) set 18 targets that were aimed at significantly reducing disease, illiteracy, gender inequality, hunger, and poverty, and improving access to water and sanitation by 2015. Leading up to this point where the era of the MDGs concludes, progress has been monitored and discussions started well ahead of this momentous year to define and meet the more ambitious Sustainable Development Goals (SDGs), building on and bringing to fruition what has been started under the MDG agenda. Much progress has been made toward achieving the MDGs. The world reached the poverty reduction target five years ahead of schedule, and progress has been reported in a number of other areas. However, considerable challenges remain: even while declaring success on MDG1, roughly a billion people remained in poverty. A large number of MDG targets will not be met by the end of 2015, and progress remains uneven among the different countries. Moreover, new challenges to progress are emerging deriving from natural and manmade calamities. To deliver on the twin goals and the post-2015 agenda, the Bank Group would benefit from a clearly articulated role, approach, and expected contribution to the SDGs, both externally for enhancing partnerships and internally to facilitate prioritization and synergies. As this paper has shown, the World Bank Group works actively in many areas relevant to the SDGs, actually many more than covered here, but various evaluations have pointed to the importance of multi-sector integrated approaches that challenge countries and their partners to find new ways of working. The challenges that the SDGs aim to address, and the SDGs themselves, are complex, and solutions will have to be tailored to context, bring together multiple actors, and benefit from dynamic, constantly adjusted planning and execution that is informed by ongoing monitoring and evaluation.

Madagascar’s education system exhibits severe weaknesses that leave a large number of children without the basic skills required to function in the labor market. Since the start of the political and economic crisis in 2009, progress made on key health indicators has stagnated or is being reversed with Madagascar falling off track to achieve the MDGs. The prevalence of chronic malnutrition among children under five is one of the highest in the world. Maternal mortality ratios also have remained relatively high and stagnant over the last ten years and the country.

This paper lays out a roadmap to achieve social justice in healthcare by prioritizing areas related to service delivery, financial protection, and quality of care. The aim is to assist the Government of Egypt (GoE) in realizing the principle of social justice in the provision of healthcare. In doing so, the roadmap aims to prioritize key areas of focus for Egypt, including describing which existing programs to continue supporting and which new programs to consider for development, all under an integrated and interdependent structure. It is a focused assessment of how the overarching aim of social justice can be achieved in the healthcare sector through an emphasis on improving services for the most disadvantaged groups. This roadmap suggests recommendations that will result in incremental improvements in Egypt’s healthcare system in the short to medium term with a focus on disadvantaged groups. Achievement of these results should situate Egypt on the path to achieving social justice in healthcare in the long term.

This report presents an analysis of the early childhood development (ECD) programs and policies that affect young children in Albania and recommendations to move forward. This report is part of a series of reports prepared by the World Bank using the systems approach for better education results (SABER) - ECD framework and includes analysis of early learning, health, nutrition, and social and child protection policies, and interventions in Albania, along with regional and international comparisons.

The World Bank supported the community nutrition project (CNP) in the Lao People’s Democratic Republic (PDR) from 2009 to 2013, ostensibly to respond to the global food crisis of 2007-08. The evaluation finds an attributable effect on only one of the six formal project indicators: children in intervention areas were more likely to receive full diphtheria, pertussis, and tetanus (DPT) vaccines. This impact evaluation seeks to address whether the CNP can make causal claims to improving indicators related to its six stated project development objective measurements for mothers and children under two years old: antenatal care visits, institutional delivery, well-child checkups, breastfeeding, immunization, and diarrhea oral rehydration solutions. The results of quasi-experimental impact evaluation methods indicate that although general effects for these outcomes are mixed, the project shows improvements for the poorest 40 percent of the population.

This is a policy note following from the book Health Financing in the Republic of Gabon. The book is a comprehensive assessment of health financing in the Republic of Gabon. The book reviews the health financing situation in light of the government’s introduction of a national health insurance program and its commitment to achieving universal health insurance coverage in the medium term. The book provides a diagnostic of the situation in light of recent data from the demographic and health survey, updated national health accounts, and a review of public expenditures in the health sector. Additionally, it performs a benchmarking exercise to assess how Gabon performs in its health spending and health outcomes compared to countries of similar income and compared to countries in the region. A forthcoming household survey is expected to provide better information on financial protection against illness costs. This book attempts to diagnose Gabon’s current situation in regards to achieving universal health coverage. Gabon should be commended for its commitment to improving health indicators of the poor and the underserved. The book shows that while the government has set an ambitious goal for itself, several challenges exist in meeting these objectives in the medium term as follows (i) resource mobilization efforts are a priority to sustain its programs financially; (ii) to prioritize resources for areas considered, value for money, to improve equity in access and delivery of health services, with particular focus on primary care, public health program, and quality of care; (iii) to increase the population’s coverage under the national health insurance program, with focus on the poor and the informal sector workers; and (v) to consider areas that would improve efficiency and reduce costs. The book is timely, given that the government has recently produced, the Plan Social. It provides a diagnostic of the health sector and provides key recommendations and options for the government to consider in the short to medium term.

School health and nutrition (SHN) programs are critical for achieving education for all (EFA) as research has shown that improvements in health status contribute to improvements in learning and academic outcomes. Through programs targeted to address major health conditions that are highly prevalent among poor schoolchildren, (for example, iron deficiency anemia, hunger, worm infections, diarrheal disease, and malaria) SHN programs can have a large impact on children’s education, increasing the time that they spend at school and their ability to learn while at school. SHN programs are recognized as important educational policy initiatives to improve education outcomes. Furthermore, schools provide an excellent platform for the delivery of child health and nutrition services, where they can strengthen the cost-effectiveness of health interventions and deliver gains in participation and learning. In this paper, the policy platform is documented as well as the type, coverage, and the effect of the SHN interventions, followed by the key areas identified for development and learning of the school health promotion program (SHPP).

The KP aims to support the Bank in adopting a significantly more systematic approach to multisectoral action in countries to maximize investment in other sectors for health results, in line with its comparative advantage. It will help to meet the Bank s twin goals and add value to its work in countries, by providing task teams with data on the burden of disease and risks and their upstream determinants, which multisectoral action could address, toward the goal of reducing poverty. It will assist in demonstrating the links between upstream determinants, such as poverty and inequality, and health outcomes. KP will identify proven and cost-effective multisectoral solutions from international best practice that have the potential for transferability to local contexts. It will then help understand the drivers, opportunities and constraints of work across practices and sectors on a common agenda to meet the Bank s goals. Finally, contributing to the effective delivery of existing Bank work across sectors within countries, and provide foresight and priorities for future action.

Global alliance for vaccines and immunization (GAVI) is the third largest multilateral in the health sector. It has a single-purpose mandate, to increase access to immunization in poor countries. The World Bank is a founding partner to GAVI and remains a major partner, particularly at a financial level by supporting operations of two major innovative financial mechanisms on its behalf. The Bank’s most significant contribution is a key role in the establishment and management of two innovative financing mechanisms (International Finance Facility for Immunisation (IFFIm) and Advanced Market Commitment (AMC)) that have contributed one-third of GAVI’s financial resources from 2000 to 2010. The relationship with GAVI has been collegial and constructive in countries where there is engagement, but in many countries the Bank is not substantially involved in immunization. This review concludes that the status quo leaves organizational synergies untapped, and that stronger Bank involvement, drawing on its strengths in sustainable funding for immunization, addressing inequities in access to immunization, investments in health systems strengthening, and donor coordination in health can help achieve greater development results.

The purpose of this discussion paper is to assist countries in exploring synergies in service delivery and disease dynamics that can positively affect both non-communicable diseases (NCDs) and the Millennium Development Goals (MDGs). The paper examines the challenges countries face in addressing both infectious and non-communicable diseases, and highlights examples of integrated interventions in addressing this double burden of disease. Many low- and middle-income countries are faced with a rising burden of NCDs while working to improve health outcomes to meet health-related MDGs. This dual challenge takes place in an environment of increasingly limited resources, which is why the efficient integration of prevention, diagnosis and treatment of NCDs with MDG-related activities will be, in many instances, the best option these countries will have to address such challenges. Brazil’s Family Health Program and Turkey’s Health Transformation Program provide useful examples to draw on, and have been highlighted in this paper. Both programs have demonstrated impressive results, which can serve as an impetus for countries to take action.

This report presents an analysis of the early childhood development (ECD) programs and policies that affect young children in the Democratic Republic of Congo and recommendations to move forward. This report is part of a series of reports prepared by the World Bank using the systems approach for better education results (SABER) - ECD framework and includes analysis of early learning, health, nutrition, and social and child protection policies, and interventions in Democratic Republic of Congo, along with regional and international comparisons.

This study was jointly undertaken by the Climate Change and Health Promotion Unit of the Ministry of Health and Family Welfare, the International Centre for Diarrheal Disease Research, Bangladesh, and the World Bank. This study had two broad objectives: (1) to assess national vulnerability and impact on major diseases of increased climate variability and extreme events in Bangladesh; and (2) to assess existing institutional and implementation capacity, financial resources at the local level, and existing public programs targeted at climate-sensitive diseases.

This report presents an analysis of the early childhood development (ECD) programs and policies that affect young children in the Gambia and recommendations to move forward. This report is part of a series of reports prepared by the World Bank using the systems approach for better education results (SABER) - ECD framework and includes analysis of early learning, health, nutrition, and social and child protection policies, and interventions in the Gambia, along with regional and international comparisons.

This report presents an analysis of the early childhood development (ECD) programs and policies that affect young children in Mali and recommendations to move forward. This report is part of a series of reports prepared by the World Bank using the systems approach for better education results (SABER) - ECD framework and includes analysis of early learning, health, nutrition, and social and child protection policies, and interventions in Mali, along with regional and international comparisons.

This section describes the priority nutrition interventions and cross-cutting approaches that are essential to promote and protect the nutritional status of mothers and children as well as a country's human capital in the short-, medium-, and long-terms. The main thrust of the guidance is that: (1) policies give special attention to the critical 'window of opportunity' represented by the first 1,000 days of life; (2) policies are aligned with the latest international recommendations in nutrition; (3) policies and interventions of key sectors are coordinated to provide synergy of action; and (4) resources allocated for disaster prevention and emergency management are invested in the most cost-effective way. Monitoring is a continuous process of collecting and analyzing information to better understand how well a program is operating against expected outputs and to allow remedial intervention to correct failures. Situation monitoring measures the change or lack of change, in a condition or a set of conditions and includes monitoring of the wider context. Performance monitoring, on the other hand, measures progress in achieving specific results in relation to an implementation plan. Evaluation is a systematic and objective assessment that attempts to determine the worth or significance of an intervention, strategy, or policy. It is used to appraise the effectiveness of an intervention to determine if it meets its goals, to estimate its results or impact, and to identify its costs vs. its benefits. Promote optimal breastfeeding practices. Provide all pregnant women with daily iron-folic acid supplements for at least six months. Provide deforming treatment to pregnant women, preschool-aged children, and school-aged children in areas where hookworms or soil-transmitted helminthes are prevalent. Establish strong links between agricultural, food security, social protection and nutrition policies that can be used to inform a robust communication program regarding maternal diet and critical infant and young child feeding practices. Support diversified agricultural production to increase availability of nutrient-dense foods, particularly those of animal sources.

The nutrition cluster is a very important entity to coordinate actions during emergencies. It is important that the nutrition cluster know in advance which institutions work where and what kind of inputs are pre-positioned. Risk management plans need to be ready at the local level in advance of emergencies. Although emergencies occur every year in Guatemala, the emergency response often fails to incorporate the management of malnutrition among its priority actions. Community programs, like AIN-C (a community- based child care program - atencion integral a la ninez comunitaria), can be an efficient mechanism to protect young children's nutrition and provide an important channel for the government or other assistance agencies to funnel support to communities in need during a period of crisis or emergency. This is because community workers know the families and those who are most vulnerable; they are willing to be called upon to help their community; and they can provide educational support to families to ensure rapid recovery among young children. Community-based growth promotion programs such as AIN-C can be strengthened and scaled up, and they are a good investment, in the aftermath of an emergency or during a time of economic crisis, to swiftly deliver services to affected families. Community agents can carry important information to the community and can distribute food, nutrition and health supplements such as micronutrient powders and oral rehydration salts for young children, as well as hygiene and water purification products. Community kitchens are an efficient approach to reduce hunger among the poor during times of high economic stress. They provide a social safety net and can have a nutrition effect when carefully planned. Community kitchens adjust to the labor market and general economic conditions; hence targeting of the poor and most in need through community kitchens is self-selective. The kitchens can expand and shrink as participants continually assess the trade-off between unpaid work in exchange for free or inexpensive meals and the pursuit of opportunities in the labor market.

The health equity and financial protection datasheets provide a picture of equity and financial protection in the health sectors of low- and middle-income countries. Topics covered include: inequalities in health outcomes, health behavior and health care utilization; benefit incidence analysis; financial protection; and the progressivity of health care financing. This report show how health outcomes, risky behaviors and health care utilization vary across asset (wealth) quintiles and periods. Benefit-incidence analysis (BIA) shows whether, and by how much, government health expenditure disproportionately benefits the poor the distribution of subsidies depends on the assumptions made to allocate subsidies to households. This reports whether overall health financing, as well as the individual sources of finance, is regressive (i.e. a poor household contributes a larger share of its resources than a rich one), progressive (i.e. a poor household contributes a smaller share of its resources than a rich one) or proportional.

The health equity and financial protection datasheets provide a picture of equity and financial protection in the health sectors of low-and middle-income countries. Topics covered include: inequalities in health outcomes, health behavior and health care utilization; benefit incidence analysis; financial protection; and the progressivity of health care financing. The tables in this report show how health outcomes, risky behaviors and health care utilization vary across asset (wealth) quintiles and periods. The quintiles are based on an asset index constructed using principal components analysis. Benefit-Incidence Analysis (BIA) shows whether, and by how much, government health expenditure disproportionately benefits the poor. The distribution of subsidies depends on the assumptions made to allocate subsidies to households. Under the constant unit cost assumption, each unit of utilization is assumed to cost the same and is equal to total costs incurred in delivering this type of service divided by the number of units of utilization.